Post Acute, Long Term Care, & Home...

Owensboro Health

• 477 Bed Regional Hospital

• 32 Bed ICU• 30 Transitional Care Beds• Level III Trauma Center• Level III NICU• Largest employer west of

Louisville in the Commonwealth of Kentucky

Bill J. Bryant, MD FAAFP CPPS CMD

• CAQ (Geriatrics)

• Owensboro Health– Chief Quality & Patient Safety

Officer– Medical Director of the Transitional

Care Center

• Bill.Bryant@OwensboroHealth.org

Focus on Delirium and Care of the Aging:

A Crosscutting Approach

Delirium:

November, 2016

Joseph H. Flaherty, MDProfessor and Associate Chair of MedicineGeriatrics DivisionSaint Louis University School of Medicine

“one of the most challenging patients in health care is the “agitated delirious patient.”

Just as challenging, for different reasons, is the lethargic confused patient who “just isn’t getting better”.

The patient …was both.

Joseph H. Flaherty, MD

American Delirium Society website. Accessed 2/7/16

Delirium is an acute decline in cognitive function and attention and represents acute brain failure.

Review: Postoperative Delirium in Older Adults: Best Practice StatementSharon K. Inouye MDThomas Robinson , MD, MS, FACSFebruary 2015 Volume 220, Issue 2, pages 136–148.e1

Consider Acute Kidney Failure analogy

Hospital management of older adults Author Melissa Mattison, MD, SFHM Section Editors Kenneth E Schmader, MD Andrew D Auerbach, MD, MPH Deputy Editor Lee Park, MD, MPHUpToDate Literature review current through: Jan 2016. | This topic last updated: Jun 15, 2015. Accessed February 7, 2016

Objectives:

Define delirium and hospitalization associated disability as geriatric syndromes, and their negative impact on clinical and functional outcomes of the older patient.

By considering current limitations and shortcomings within a historical perspective, promote an innovative vision for a more holistic model of management for the frail elderly patient to achieve optimal outcomes.

Describe the organizational crosscutting impact of this model in reducing harm events and improving quality outcomes.

A new idea, device, or method

Innovation

A new idea, device, or method

Innovation

To do things differently,

we must see things differently.

John Kelsch, Xerox, Quality Healthcare in America Project

This is not my mom!

https://www.youtube.com/watch?feature=player_detailpage&v=9QURzexhWP4

Adapted from Feldman & Gracon, 1996

American Journal of Medicine. May, 1999. 106 (5): 563-573

1900

• 47 yrs

1925

• 57 yrs

1950

• 68 yrs

1975

• 73 yrs

2000

• 78 yrs

2012

• 78.8

“Third leading cause of death behind heart disease and

cancer”Journal of Patient Safety, September 2013, Volume 9, Issue 3

251,000 2016

Martin Makary. BMJ 2016;353:i2139

A Prediction

(Life Expectancy average of male and female ages)(2012 Source: USA Today dated October 9, 2014. Accessed 10/16/16

…frail patients are at risk for marked and often disproportionate decompensation,…

adverse events, procedural complications, prolonged recovery, functional decline, disability, and mortality.

Frailty Assessment in the Cardiovascular Care of Older Adults. Jonathan Afilalo et al. Journal of the American College of Cardiology. Vol. 63, (8): 747-762. 2014

1900

• 47 yrs

1925

• 57 yrs

1950

• 68 yrs

1975

• 73 yrs

2000

• 78 yrs

2012

• 78.8

(Life Expectancy average of male and female ages)(2012 Source: USA Today dated October 9, 2014. Accessed 10/16/16

• Institute of Medicine (IOM) reports on challenges … as the population ages.

1978:

• 1st Geriatric Certifying examination

1988:

• The challenge: geriatric medicine is a young discipline…

•John A. Hartford Foundation accessed 10/11/2015

2015

• IOM Report:

• Scarcity of faculty

• Few providers choose this career

• Decreasing number…

• entering training programs

• choose to recertify

2008

Ten Ways to Improve the Care of Elderly Patients in the Hospital. Angelena Maria Labella et al. Journal of Hospital Medicine 2011; 6: 351-357.

Hospitalists care for elderly patients daily, but few have specialized training in geriatric medicine. ^

13% of population

40% of hospitalized patients

1.8% of population

8% of hospital discharges

Source: UpToDate: Accessed 1/15/2016AHRQ

Source: UpToDate: Accessed 1/15/2016Agency for Health Care Policy and Research. Rockville, MD 2010

Pediatrics

Geriatrics

© 2016 Bill J. Bryant ALL RIGHTS RESERVED

Pediatrics

Geriatrics

© 2016 Bill J. Bryant ALL RIGHTS RESERVED

Review: Postoperative Delirium in Older Adults:

Best Practice Statement

Sharon K. Inouye & Thomas Robinson

February 2015. Volume 220, Issue 2, pages 136–148.e1

Review: Postoperative Delirium in Older Adults: Best Practice StatementSharon K. Inouye MDThomas Robinson , MD, MS, FACSFebruary 2015 Volume 220, Issue 2, pages 136–148.e1

(AD = Alzheimer’s Disease)

The hallmark of delirium is acute cognitive change from baseline.

Source: NIH

Delirium is a serious complication for older adults…

Review: Postoperative Delirium in Older Adults: Best Practice StatementSharon K. Inouye MDThomas Robinson , MD, MS, FACSFebruary 2015 Volume 220, Issue 2, pages 136–148.e1

…an episode of delirium can initiate a cascade of deleterious clinical events …

including other major postoperative complications,

prolonged hospitalization,

loss of functional independence,

reduced cognitive function,

and death.

0

5

10

15

20

25

30

0 1 2 3 4 5 6 7 8 9Years

Normal Pre-ClinicalMild

Cognitive Impairment

Mild -- Moderate -- Severe -- Dementia

Brain Photo Source: NIH Adapted from Feldman & Gracon, 1996

Terra Crabtree’s Video here

• here is the YouTube link

– https://youtu.be/bh5-cey-uYY

• Here is the Dropbox link:

– https://www.dropbox.com/s/fa8j8of4oqe7wt7/Terra%20Edit.mp4?dl=0

Delirium is Serious

Often Fatal: Higher mortality rates

• at 1 month (14% vs. 5%),

• at 6 months (22% vs. 11%)

• at 23 months (38% vs. 28%); • Compared to hospitalized patients with no delirium after adjusting for age, gender, race,

and comorbidityReview: Postoperative Delirium in Older Adults: Best Practice StatementSharon K. Inouye MDThomas Robinson , MD, MS, FACSFebruary 2015 Volume 220, Issue 2, pages 136–148.e1

Delirium initiates a cascade of deleterious clinical events

Longer hospital lengths of stay

• (21 vs. 9 days)

Higher probability of long-term care• at discharge

• 47% vs. 18%

• 6 months

• 43% vs. 8%

• 15 months

• 33% vs. 11% and

a higher probability of developing dementia at 48 months• 63% vs. 8%

Compared to hospitalized patients with no delirium

after adjusting for age, gender, race, and comorbidity)

Review: Postoperative Delirium in Older Adults: Best Practice StatementSharon K. Inouye MD Thomas Robinson , MD, MS, FACSFebruary 2015 Volume 220, Issue 2, pages 136–148.e1

Rates of persistent delirium …

• at discharge = 45%

• 1 month = 33%

• 3 months = 26%

• 6 months = 21%.• Among hospitalized patients who survive their delirium episode

Delirium persists

Review: Postoperative Delirium in Older Adults: Best Practice StatementSharon K. Inouye MD Thomas Robinson , MD, MS, FACSFebruary 2015 Volume 220, Issue 2, pages 136–148.e1

•considered a less serious event

•not recognized

Delirium is often…

Review: Postoperative Delirium in Older Adults: Best Practice StatementSharon K. Inouye MDThomas Robinson , MD, MS, FACSFebruary 2015 Volume 220, Issue 2, pages 136–148.e1

Effect of Delirium and Other Major Complications on Outcomes after Elective Surgery in Older Adults. Lauren J. Gleason et al. JAMA Surgery. September 9, 2015

…It is imperative that clinicians caring for surgical patients understand optimal delirium care.

Review: Postoperative Delirium in Older Adults: Best Practice StatementSharon K. Inouye MDThomas Robinson , MD, MS, FACSFebruary 2015 Volume 220, Issue 2, pages 136–148.e1

•is preventable in up to 40% of cases.

Delirium…

Review: Postoperative Delirium in Older Adults: Best Practice StatementSharon K. Inouye MDThomas Robinson , MD, MS, FACSFebruary 2015 Volume 220, Issue 2, pages 136–148.e1

Delirium and the “Know-Do” Gap…

…Hshieh et al combined the results from 14 high quality trails studying multicomponent non-pharmacological interventions involving 4267 patients and found that these simple interventions reduced delirium by 53%.

Meta-analysis of Delirium Prevention. Delirium and the “Know-Do” Gap in Acute Elders. S. Ryan Greysen MD. JAMA Internal Medicine April, 2015. vol. 175, number 4

Delirium and the “Know-Do” Gap…

Meta-analysis of Delirium Prevention. Delirium and the “Know-Do” Gap in Acute Elders. S. Ryan Greysen MD. JAMA Internal Medicine April, 2015. vol. 175, number 4

Consider if a new medication or technology achieved such outcomes.

These results are even more striking considering that delirium is the number one predisposing factor for falls.

…Hshieh et al were able to demonstrate a 62% reduction in falls owing to these interventions…

Disability

Comorbidity Multimorbidity

FrailtyGeriatric

Syndromes

Cognition

Geriatric Principles

Geriatric Syndromes

are clinical conditions common in older adults that share underlying causative factors and involve multiple organ systems.

Geriatric Syndromes in Hospitalized Older Adults Discharged to Skilled Nursing Facilities. Susan P. Bell, Eduard E. Vasilevskis et al. JAGS. 64: 715-722. 2016

Examples:

Incontinence

Cognitive impairment

Delirium

Falls

Pressure ulcers

Pain

Weight loss

Anorexia

Functional decline

Depression

Multimorbidity.

They include a number of clinical conditions that, unlike traditional syndromes, do not fit a discrete disease category.

A geriatric syndrome is a multifactorial condition occurring primarily in frail elderly which is usually due to multiple contributing factors and results from an interaction between patient-specific impairments and situation–specific stressors.

Ten Ways to Improve the Care of Elderly Patients in the Hospital. Angelena Maria Labella et al. Journal of Hospital Medicine 2011; 6: 351-357.

“Ten Evidence Based Pearls for care of the older hospitalized patient”

Complexity

Polypharmacy: Discussion:

• …medications may contribute to or exacerbate geriatric syndromes alone or through drug-drug or drug–disease interactions.

Guidelines Abstracted from the American Geriatrics Society Guidelines for Improving the Care of Older Adults with Diabetes Mellitus: 2013 Update. American Geriatrics Society Expert Panel on the Care of Older Adults with Diabetes MellitusJAGS 61: 2020-2026, 2013 (Journal of American Geriatrics Society)

Complexity

"Any symptom in an elderly patient should be considered a drug side effect until proven otherwise."

J. Gurwitz, 1995

^

Paradigm ofGeriatric Syndromes

…rarely explained by a single cause.

Covinsky et al JAMA. 2011; 306(16):1782-1793

Can we check a urine????

Simplicity

As common as UTIs are in nursing home residents, asymptomatic bacteriuria is more common, occurring in > 30% of NH residents, and 100% of those chronically catheterized.

Every day, frail older patients are evaluated with unnecessary urine tests, incorrectly labeled with a UTI diagnosis, and treated with potentially harmful therapy.

Scapegoating of UTIs for the myriad behavioral and functional changes that occur commonly in frail older patients may delay identification of the correct diagnosis.

Less is More: Challenging the “Culture of Culturing”. The Case for Less Testing and More Clinical Assessment

Heidi L. Wald, MDU. of Colorado School of Medicine

This approach differs from the traditional medical approach…

Ten Ways to Improve the Care of Elderly Patients in the Hospital. Angelena Maria Labella et al. Journal of Hospital Medicine 2011; 6: 351-357.

New way of thinking

Comparison of Two Approaches to Geriatric Syndromes using Falls as an example

TraditionalGeriatric

Geriatricians think and see things differently

It ain’t what you don’t know that gets you into trouble.

It’s what you know for sure that just ain’t so.

Mark Twain

A potent risk factor for the Hospitalization Disability Syndrome

Age

44Covinsky et al JAMA. 2011; 306(16):1782-1793

30% of adults > 70 y.o. hospitalized for a medical illness are discharged with an ADL disability they did not have before becoming acutely ill.

> 50% of adults > 85 y.o. leave the hospital with a major new ADL disability

Ten Ways to Improve the Care of Elderly Patients in the Hospital. Angelena Maria Labella et al. Journal of Hospital Medicine 2011; 6: 351-357.

Functional decline during hospitalization is … associated with poor prognosis.

A “Cascade to dependency”…

• In one study of elderly patients with new ADL disability at discharge, over 40% were dead by 12 months after discharge, and only 30% returned to baseline function.

1 in 5 older adults is taking potentially inappropriate medications in the office and

community settings

1 in 6 hospital admissions of older adults is because of an adverse drug event

(4X > younger persons).

> 75 yo: 1 in 3 hospital admissions is because of an adverse drug event

1 in 6 older patients experiences an adverse drug event while in the hospital

Estimated that 12-17% of general medical patients experience ADEs after hospital discharge,

• a large percentage of which may be preventable.

In 45 days period after hospitalization an event identified in nearly 1 in 5 discharges.

> 1/3 ADEs considered preventable

More severe events were more likely to be preventable…

Medications to Avoid or Use with Caution in Older People

>40 medications or medication classes

Divided into 5 categories

Journal of American Geriatrics Society. 2015

Special Communication: Less is More.

Reducing Inappropriate Polypharmacy.

The Process of Deprescribing. Ian A. Scott et al. JAMA Intern Med. 2015; 175 (5): 827-834

Deprescribing

Dynamic

• The systematic process of identifying and discontinuing drugs in instances in which existing or potential harms outweigh existing or potential benefits…

• Is part of the good prescribing continuum which spans therapy initiation, dose titration, changing or adding drugs, and switching or ceasing drug therapies.

Adapted from Ian Morrison: The Second Curve. Managing the Velocity of Change

Volume Based First Curve

Value Based Second Curve

Adapted from:Hospitals in Pursuit of Excellence. Accelerating Performance Improvement. HRET. April 2013Accessed 10/15/16

Functional Status

Cognitive Status

Mental Status

(More…)

Value =Quality

Cost

• 60-90-120-365 Day Mortality

• 60-90-120-365 Day Readmission

• Functional Outcomes

• Cognitive

• Mental

• Physical

• Hospital Acquired Infection

• Harm Events

• Communication & Coordination of Care

• Medicare Spending Per Beneficiary expansion

• 60-90-120- 365 Days

• Total Cost

• Ambulatory

• Imaging

• Laboratory

• Hospitalization

• Skilled Nursing Facility

• Home Health, Etc.

A Prediction:

Adapted from Ian Morrison: The Second Curve. Managing the Velocity of Change

Evidence Based Medicine:

• Geriatrics Principles

• Internal Medicine Principles

Safety & Reliability Focus

• First do no harm

• Less is more

Patient Centered Care

• Optimal Outcomes for Older Patients

Adapted from Ian Morrison: The Second Curve. Managing the Velocity of Change

? 100 years old

Value Based Second Curve

The Art of Medicine

Relentless Mindfulness